A recent letter to the editor of Emerging Infectious Disease (EID), published by the CDC, discusses a case of Israeli Spotted Fever as the cause of death in a traveler who cruised the Mediterranean. The article citation and link can be found here:
Boillat N, Genton B, D’Acremont V, Raoult D, Greub G. Fatal case of Israeli spotted fever after Mediterranean cruise [letter]. Emerg Infect Dis. 2008 Dec; [Epub ahead of print]
For those of you reaching for a textbook, let me save you some time…I already had to look it up.
Basics: Caused by Rickettsia conorii (sub-species israelensis) and closely related to Mediterranean Spotted Fever, this bacteria is intra-cellular and gram negative. Spread by the bites of infected ticks, lice and fleas, common symptoms include fevers, rash, bleeding from nose, hepatomegaly and a eschar at the site of the initial bite. This is typically a self-limited disease and has fatality rate of < 3%, even without treatment.
Location: Worldwide, with region specific illness (and nicknames) common. Examples include Mediterranean Spotted Fever, South African tick-typhus, tsutsugamushi and many others.
Transmission/Prevention: Transmitted though the bite of an infected tick, body lice, or chigger. Rocky Mountain Spotted Fever (RMSF) is transmitted through the tick Dermacentor variabilis or D. andersoni. Prevention is basic sanitation, prevention of bites through permethrin treated clothing and frequent tick-checks.
Treatment: Antibiotic treatments include doxycycline, typically for 5-7 days or 48 hours after a patient is afebrile.
The case report notes that the patient died, even with adequate treatment. The authors also pointed out that delayed antibiotics (6 days) could have been a factor in this unusual cause of mortality.
The location where this illness was contracted is also another question. His trip took him through Crete, Libya and Malta. Again, the authors speculate that he acquired the infection in Libya, where he spent several days touring the ruins of Appolonia, Sabratha and Ptolemais. The incubation period of 7-8 days places him in Libya, prior to onset of symptoms. Death was eleven days after the initial symptoms and occurred in Switzerland.
This article hopefully reminds everyone to think about a rickettsial disease in a febrile traveler, especially with a rash. No history of a tick bit or insect bite was noted, in this case. Frequent tick-checks can also be helpful and a source of bonding with your travel companions. These insects seem to like areas of the body where hair grows.